0111-026 (AR)7Chap:SIENSED CONTRACTOR DECLARATION ,
t
under penalty of perjury that I am licensed under provisions of
r 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's'
License Law for the following reason:
(y) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business &Professionals Code).
( ) I, as owner' of the property, am exclusively contracting with licensed
contractors' to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&PC. for this reason
Date 1 1 zti Signature of OwneFi r �-
�' WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one .of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:.
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for' a permit subject to the conditions and restrictions set forth on his
application. ,
1. Each person upon,whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
LSignature (Owner/Agent,"19+-�I•• Date 11 ?'? .
`.�,+,•r►- BUILDING PERMIT PERMIT#
DATE VALUATION LOT M'ti'_026 TRACT
JOB SITE
ADDRESSID0, e lean �A
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
BRM F &. n RROVM
51.850 AMEN AMORAT
LA Q1:f1lrt: -LA Chi: 92M
,.
USE OF PERMIT
ROOM .f1,9iM1.'T1014 YORBITL(,MOONI H.S ITI (414 S?)
TRACT CONSTRUCTION 4.14.00 SY
i4 " A��S' MID coot C' F ��0 IR�i�'�C9n
t:,01?tS`aAUCTION FEE I�5��$Q)t�'.p..�l�PofDi�L;
PLAN CHECK ME , I 01A
Wt 1T.Aidi CM, FEE 101.000.421.000 N940
R,J, .CTR1CAL "f?Ptd 101-000-420-000
141 -000 -4191 -?1
�.1�
�t5�l.�,lty).rlr9y,1���:ltfiyi ��ry'L•tR•c�l
:7'1 R F , 619 4VFW • k R f/d`4 f 7'<% r 1S i nY6 / , MI -000-241-000
GfdAW40 RIS; 101000-42,1. 00 $200
r j• i ., -
r�
WY OF LAQU114TA
RECEIPT
DATE
BY4-1 -
DATE FINALED
INSPE
4
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
I - 2A. O A--
Return Air
Steel
Combustion Air
Roof Deck
1 p
Exhaust Fans
O.K. to Wrap
.p
F.A.U.
Framing
Compressor
Insulation
(lle__
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'7 b Z
Drywall - Int. Lath
-
Final
_ _
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Q'L
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final g
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
—7.c'l
WE
�b2�lij %rat
'Rig #City
v
of La Quinta
Building 8i Safety Division
P.O. Box 1504, 78=495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
.D/// OZ,/o
Project Address
4
Owner's Name:
A. P. Number:Address:
Legal Description:
Contractor:
Address:
City, ST, Zip �
Telephone:
Project Description:
City, ST, Zip:
y
Telephone, hone: G v
r�
T
State Lic. # :
Arch., Engr., Designer: -
City Lic. #:
Q
Address:
City, ST, Zip: lr ��
Telephone: -
.
tate i #
S Lc. —
e
Name of Contact Person: Z�
2
Construction onT
Type: e:
occupancy:
r JPe ct type (circle rc
le one : New w Add' n Alter Repair Demo
Sq. Ft.: 6j #Stories: / F#Units: - —
Telephone # of Contact Person:
G
Estimated Value of Proiec .
Z
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING PERMIT FEES
Z
Plan Sets
Z cW
Plan Check submitted / zs Item
Amount
Structural Calcs.
Reviewed, ready for corrections ��/� Plan Check Deposit
Truss Calcs.
Called Contact Person 1/4 d I Plan Check Balance 6
Z
Title 24 Calcs.
Z
Plans picked up I 1/g Construction
Flood plain plan
Plans resubmitted 11 Mechanical
Grading plan
2"a Review, readyr correcti s/issue / $ Electrical
Subcontactor List
Called Contact Person 3/D= Plumbing
Grant Deed
Plans picked up /4 S.M.I.
H.O.A. Approval
Plans resubmitted I'ID, lv,2, Grading t
IN HOUSE:-
'"' Review, ready for correctio issue a� eveloper Impact Fee
Planning Approval
Called Co er a� 0 A.I,P,P,
Pub. Wks. Appr
74
Date of rmit issue
School Fees
Total Permit Fees
VK pe— � e
4
Desert Sands Unified School District ,
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 1/22/02 APN# 773-152-006
No. 22851 Jurisdiction La Quinta
Owner NameBrian & Esther Brown Permit #0111-026
• A
No. 51850 Street Avenida Morales Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 414
Type of Development Residential Addition No. of Units 1
Comments
C
Tract Construction- Residential room addition for Bedroom & Bath 414 sq.ft.
At the present time, the Desert Sands Unified School' District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined the above-named owner is exempt from paying school fees at this time due to the following reason:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
0.00 X 414 or $ 0.00 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now,be,issued
Fees Paid By Exempt- Brian Brown Telephone '760-564-7048
Name on the check "
By Dr. Doris Wilson
• Superintendents .
Fee collected /exempted by Nicola Wong Exempt "-J$0.00 Eo
Check No. - • . , z
Signature w
FNOT1.1E: Pursuant to Assembly Bill 3081 (CHAP 549, ST S. 996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
begnto run from the date on which the building or installation permit for this project is sssued or on which they are paid to the Districts) or to another public entity authorized to
them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
OWNER / BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
% Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law' to put their license number on all permits for which they
1.
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection;•
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer -and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect- to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through. their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters'The' ilding permit will notbe issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING -AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760)777-7012
PX,• (760) 777-7011
OWNER'S I NATURE/DATE
SZ�12�D &�V) '
PROPERTY,ADDRESS
o!! ! - oaf
PERMIT NUMBER(s)
` CITY OF T . .
`
- ' ~���U������Z BUILDER
- �Only persons appearing onthis list mrtheir'employees are
- authorized' work, ^
ot building permit. For eacn applicable trade, all intormation requested below Must be completecl.by applicant. "un File" is not an acceptable response.
r �
`
\
raci
it t Li
Company Name
Classification
License Nurfiber
Exp. Date
Carrier Name
Policy Number
Exp: Date
License Number
Exp. D ate
(e.g. A, B, C-8)
(Xxxx, xx)
lxxlxxlxx)
(e.g. State Fund, CalComp)
(Format Varies)
(xx/xx/xx)
(xxxx)
(xxixxlxx)
MASONRY (C;,
PLUMB
ROOFI
r �
`
\